Failure to Document and Assess Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper documentation and assessment of pressure ulcers for two residents, leading to a deficiency in compliance with professional standards of practice. Resident R1, who was admitted with conditions including obesity, reduced mobility, and lumbar radiculopathy, developed a Stage 2 pressure ulcer on the coccyx. Although treatments were performed, the facility did not consistently document weekly skin assessments and measurements as required. Documentation was sporadic, with significant gaps between recorded assessments. Similarly, Resident R2, admitted with a Stage 4 pressure ulcer on the sacral region and other conditions such as a urinary tract infection and type 2 diabetes, also lacked proper documentation. The initial skin assessment and subsequent weekly assessments were not documented until nearly two weeks after admission. The Regional Nurse confirmed the absence of necessary documentation for both residents, indicating a failure to adhere to the facility's policy on skin integrity and wound management.
Plan Of Correction
Residents #1 and #2 had their wounds measured and documentation completed. A skin sweep will be completed of all residents by DON/designee to ensure all skin concerns are documented. Education will be provided to the DON by the Clinical Services Specialist. The DON will provide education to the staff RNs regarding the process of evaluating wounds on a weekly basis. New admissions will be reviewed at the AM clinical meeting for skin concerns. Audits will be completed once a week for 4 weeks to ensure wounds are evaluated on a weekly basis. Results of the audits will be reviewed at the Quality Assurance meeting.